Healthcare Provider Details

I. General information

NPI: 1396104212
Provider Name (Legal Business Name): SOON YE BANG MAT-9043
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 KALAKAUA AVE STE 105B
HONOLULU HI
96826-2450
US

IV. Provider business mailing address

1201 LILIHA ST APT 202
HONOLULU HI
96817-4642
US

V. Phone/Fax

Practice location:
  • Phone: 808-852-0202
  • Fax:
Mailing address:
  • Phone: 808-542-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-9043
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: